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The pyriformis syndrome is a rare entrapment neuropathy in which the sciatic nerve is compromised by the pyriformis muscle or other local structures. It is an important cause of buttock pain that may often be accompanied by sciatica. The pain is usually increased by muscular contraction, palpation or prolonged sitting. The diagnosis relies on the clinical presentation and the electromyelography (EMG) findings. Other causes of symptoms should be excluded by careful examination and detailed neuroradiological studies of the lumbosacral spine, sacro-iliac and hip joints. A case of this syndrome seen in a 36-year-old man who recovered by CT-guided corticosteroid injection is reported.

Material: We report our experience between May 1996 and May 2003 with 2200 patients affected by low back pain or sciatica due to herniated disk treated by intradiscal and intraforaminal oxygen-ozone injection. The patients received medical and physical therapy before treatment for at least 2 months; the patients with conus-cauda syndrome and hyperalgesic sciatica were excluded. We never performed discography before the treatment that was performed under CT guidance or fluoroscopy. CT provided monitoring of gas distribution in the disk and epidural space., Results: No side effects were recorded at short and long-term follow-up. Clinical results were evaluated with the modified McNab method showing an 80% success rate and 20% failure rate in 1750 patients followed up to 6 months while the success rate dropped down at 75% and failure increased at 25% in 1400 followed up to 18 months. CT showed reduction in the size of the herniated disk in only 63% of the followed patients (420 patients). The failure has been mostly related to: calcified herniated disk; spinal canal stenosis; recurrent herniated disk with epidural fibrosis; small descending herniated disk at the level of the lateral recess., (Copyright 2004 Masson, Paris)

Purpose: The aim of our study was to evaluate the diagnostic capabilities of computed tomography (CT) and magnetic resonance (MR) imaging in pyriformis syndrome (PS) and the long-term outcomes of CT-guided percutaneous treatment with botulinum. PS is a cause of sciatica and disability. The pain is usually increased by muscular contraction, palpation or prolonged sitting., Material and Methods: Thirty-four patients suffering from PS, suspected on the basis of clinical and electrophysiological criteria and after imaging examinations had excluded other causes of sciatic pain, had positive lidocaine tests and were treated by intramuscular injection of botulinum toxin type A (BTX-A) under CT guidance. MR sequences was performed in nine patients before treatment and after three months to evaluate the extent of muscle denervation., Results: In 30 cases relief of symptoms was obtained after 5-7 days. In four patients insufficient pain relief warranted a second percutaneous treatment which proved clinically successful. No complications or side effects were recorded after BTX-A injection. The MR examination demonstrated a change in signal intensity of the muscle in seven patients due to denervation, whereas in the remaining two cases only atrophy was detected. Larger series are necessary to confirm these preliminary results., Conclusions: CT-guided BTX-A injection in the pyriformis muscle is an emergent and feasible technique that appears to yield excellent local therapeutic effects without the risk of imprecise injection.

Piriformis muscle syndrome (PMS) is a cause of sciatica, leg or buttock pain and disability. The pain is usually increased by muscular contraction, palpation or prolonged sitting. The aim of our paper was to evaluate the feasibility of CT-guided percutaneous botulinic toxin (BTX) injection for the purpose of PMS treatment. Thirty patients suffering from PMS, suspected with clinical and electrophysiological criteria, after imaging examinations excluding other causes of sciatic pain, resulted positive at the lidocaine test and were treated by intramuscular injection of BTX type A under CT guidance. The follow-up (12 months) was performed with clinical examination in all cases and with MR 3 months after the procedure in 9 patients to evaluate the denervative process entity of the treated muscle. In 26 cases relief of symptoms was obtained after 5-7 days. In 4 patients an insufficient relief of pain justified a second percutaneous treatment which was clinically successful. No complications or side effects were recorded after BTX injection. The MR examination showed a signal intensity change of the treated muscle in 7 patients due to the denervative process of PM, whereas in the remaining 2 cases only an atrophy of the treated muscle was detected. Larger series are necessary to confirm these MRI preliminary results. The CT-guided BTX injection in the PMS is an emergent and feasible technique that obtains an excellent local therapeutic effect without risk of imprecise inoculation.

Purpose: To locate the origin of the pain during lumbar diskography by means of a limited intradiskal injection of a local anesthetic., Methods: Lumbar diskography by the direct central posterior approach was performed in 235 consecutive patients. In 17 patients, severe and persistent low back pain, with unilateral or bilateral radiation to the lower extremities, was provoked by contrast injection into only one disk. One milliliter of 1% lidocaine was then slowly injected in the center of these disks., Results: A 75% to 100% reduction of the low back pain was experienced by 13 patients, and a 75% to 100% reduction of the radiating pain was experienced by 16 patients within 60 seconds after the intradiskal injection of lidocaine. Radiographs demonstrated radial tears through the entire annulus thickness in 16 of 17 disks., Conclusion: Our results suggest that, in some patients with low back pain and unilateral or bilateral radiation to the lower extremities, the pain arises from within the disk. In these cases, pain radiating to the lower limb seems to be a referred type and seems unrelated to direct nerve root compression or irritation by a disk fragment in the epidural space.

To study the natural history of acute sciatica, 208 patients with obvious symptoms and signs of a lumbar radiculopathy (L5 and S1) were examined within 14 days of onset. A concomitant double-blind investigation of the effect of the nonsteroidal anti-inflammatory drug piroxicam was performed. The results measured by visual analog scale and Roland's functional tests showed a satisfactory improvement throughout the 4 weeks of observation. The piroxicam-treated group had same results as the control group. Based on questionnaires at months 3 and 12 approximately 30% of the patients still complained about back trouble and 19.5% were out of work after 1 year. Four patients underwent surgery during this period.

The authors relate the results of the treatment of 151 patients with the remarkable painful syndrome of long standing associated with lumbar osteochondrosis. In 74 patients of the main group, peridural administration of the synthetic opiates dipidolor and phentanyl provided effective analgesia in the lack of sympathetic denervation, arterial hypotension and tissue deafferentation. The selective action of the synthetic morphine-like opiates did not reduce the activity of the endogenous antinociceptive structures or destroyed the reflex mechanisms of sanogenesis. The economic effect obtained as a result of introduction of peridural injections of dipidolor and phentanyl into multimodality treatment of the neurological syndromes associated with lumbar osteochondrosis has been computed.

Seventy-three patients with lumbar radicular pain syndromes were treated in a prospective, randomized, double-blind fashion with either seven milliliters of methylprednisolone acetate and procaine or seven milliliters of physiological saline solution and procaine. All patients had radiographic confirmation of lumbar nerve-root compression, consistent with the clinical diagnosis of either an acute herniated nucleus pulposus or spinal stenosis. No statistically significant difference was observed between the control and experimental patients with either acute disc herniation or spinal stenosis. Long-term follow-up, averaging twenty months, failed to demonstrate the efficacy of a second injection of epidural steroids administered to the patients whose pain did not respond within twenty-four hours to an injection of either eighty milligrams of methylprednisolone acetate combined with five milliliters of 1 per cent procaine or two milliliters of sterile saline combined with five milliliters of 1 per cent procaine. Therefore, a decision to use epidural steroids must be made with the realization that we failed to demonstrate its clinical efficacy in this study and that reports of serious complications of this procedure have been published.

The effect of extradural corticosteroid injection in patients with nerve root compression syndromes associated with degenerative disease of the lumbar intervertebral discs was assessed in a double-blind controlled trial on 100 consecutive inpatients assigned by random allocation to treatment and control groups. Assessment during admission and at three months revealed statistically highly significant differences in respect of relief of pain and resumption of normal occupation in favour of the group treated by extradural injection. This treatment seems to be a valuable adjunct to the management of lumbar nerve root compression syndromes associated with degenerative disc disease.